1993, 06-08 Permit App: 93004422 SewerLAS n -r a , a5347 -Ot 3- LIMfr
Acc 1-51
SEWER CONNECTION PERMIT APPLICATION FORM
*THIS APPLICATION FORM MUST BE FILLED OUT ACCURATELY AND IN ITS ENTIRETY
AND SIGNED OR PERMIT WILL NOT BE ISSUED.
JOB ADDRESS: I2 -C-0-'
�cc1(,-rie
(IF KNOWN)
PARCEL NUMBER:
CITY: SpoKc,-o STATE=(AM ZIP CODE:
n .
OWNER NAME: �� �'�� V✓ G 1� ADDRESS: - S«e
CITY
STATE: PHONE: q 2-(,' -(.° S 3
PROPERTY OWNER PERFORMING SEWER CONNECTION INSTALLATION? (YES
CIRCLE
*IF PROPERTY OWNER
CONSTRUCTIONINSTALLING
REQUIREMENTS BEFOREFIRST
PERMIOTNISCUTILITIES
DEPARTMENT FOR ISSUED
CONTRACTOR:
(�+S
CITY :
ADDRESS: i (s?/7
STATE: LC PHONE: 9z -co
STATE CONTRACTORS LICENSE NUMBER..: S- 1 z s I( r
UTILITIES INSTALLERS PERMIT NUMBER:
INTERIOR PLUMBING ALTERATIONS? YES NO (CIRCLE ONE)
INTERIOR ALTERATION WORK BY..:
ADDRESS: PHONE:
CITY: STATE: ZIP CODE:
*ONE PERMIT REQUIRED FOR EACH SEPARATE BUILDING, SHOP, GARAGE, ETC
THAT WILL BE CONNECTED TO THE SEWER.
SEWER CONNECTION -
# OF BUILDINGS ( X 50.00 = Sb
INTERIOR PLUMBING ALTERATIONS: # OF BUILDINGS X 35.00 =
APPLICANT
SIGNATURE
TOTAL PERMIT FEE DUE $ SC.'
RECEIVED
JUN 2 1993
SPOKANE COUNTY DEPARTMENT OF BUILDINGS ..,e-t,is cMENT
WEST 1026 BROADWAY AVENUE SPOKANE,WA 99260 (509)456-3675